Mental Health Inc

by Art Levine

  Shirley White was, perhaps for the first time, being given a raw glimpse into the turmoil sweeping across her son’s mind. With Andrew’s permission, Schauland encouraged her to monitor his sleep patterns and dispense his medications. But the medical staff brushed aside her growing concerns over the prescriptions themselves. “Mother believes he is having effects from all of his sedating medications—could be alcohol withdrawal,” the social worker noted dismissively. “I can recognize his drinking,” she says now. “He didn’t hide the things he was doing.”

  In an intense phone call with the psychiatrist that same day, the pro-medication Schauland emphasized to her the importance of monitoring his prescriptions. Shirley asked, justifiably worried for her son’s safety, “Is he taking too much of his medication?” Schauland discounted that risk. The doctor also made it sound as if the VA really cared: “I conveyed to her that VA services will be available to be helpful and supportive of her efforts in her son’s behalf,” he wrote in his notes on August 3, 2007.

  Unfortunately, that turned out to be a hollow promise. The VA’s doctors just gave him more pills for his back pain, and, all too soon, more Seroquel.

  As Shirley remembers one hospital visit, the medical doctor sought to ease his reported back pain with more meds but didn’t do much else. “I can’t see anything wrong,” the doctor told Andrew. “I can’t see any problems that you’re having, but here are some pain pills that should help.” The doctor then simply grabbed samples of Vicodin for Andrew without bothering to warn him about interactions—or even recording the painkillers he dispensed in his medical records. The next day, Andrew tried to get himself admitted as a psychiatric inpatient.

  His request was denied by a hospital psychologist who viewed him as stable enough, while also noting dryly that individual therapy “may be beneficial.” Yet he never was given access to that sort of therapy until a week before his death. Later that day, he had a critical psychiatric appointment with Schauland that set him on a pathway to his death; this psychiatrist who had promised Shirley that the VA would help her son decided instead just to increase his medications. So a week after Seroquel helped put Andrew under for thirty-six hours, and knowing his history of sporadic heavy drinking, on August 8, 2007, Schauland still went ahead and resumed his prescription of Seroquel at 600 mg. That was nearly the maximum recommended dose for people with schizophrenia, and it was used as an unproven, unapproved treatment for what Schauland noted as “mood and sleep” in his records. “You use the patient as the rule of thumb,” he explains now. “You start with low dosages, then watch out for side effects. If there were any problems, I would have cut back the dosages.”

  A few days later, with all these drugs back in his system, he was driving to the Vet Center in his brand-new red Mustang on a straight stretch of road when he plowed into a car in front of him that was clearly signaling to turn. “My reaction time was off,” he told his parents later. He’d been so proud of the car, bought with a car loan two weeks earlier. Now, with the car being towed to the shop, he called his mother, who drove him to the emergency room so that doctors could examine the new back and neck pain he was experiencing. He also received more Vicodin for his pain after the ER doctors screened him for any alcohol or illegal substances, and all the tests came back negative. It was another sign that he didn’t fit the caricature used in the VA’s subsequent spin campaign—accepted by most mainstream news outlets—to essentially blame the deaths of soldiers like White on their own rampant substance abuse.

  The car accident just worsened his depression and isolation, and hastened the final, medication-fueled descent to death. His physical and mental health deteriorated as the VA gradually ramped up his medications, with the side effects of extreme weight gain and male breasts becoming more obvious. His hands and feet were shaking with uncontrollable tremors as well, but there were no positive trade-offs to justify the gradually increasing dosages of Seroquel and other drugs. They brought no new calm or stability in his life.

  Instead, he almost never left his room now, retreating into his world of Halo and other video war games until the early morning hours, the sounds of recorded gunfire echoing through the house. His nerves were more on edge, his sleep worsened, and he took almost all his meals alone in his room. From August 2007 until the day he died, he only shared a meal with his family twice. Yet in August and September, he had close to twenty different medical, psychiatric and psychological appointments, often accompanied by his mother. The periodic half-hour or so therapy sessions largely consisted of Andrew telling social workers about his anxiety, depression and insomnia, with little being done about it except doctors increasing his medication dosages.

  Getting access to care itself didn’t turn out to be Andrew’s problem with the VA; it was getting access to effective, personalized and evidence-based treatments from an agency that couldn’t keep its promises to its wounded warriors. After a thorough review of his case, the final decision that he was 100 percent disabled by PTSD and qualified to receive approximately $2,500 a month in disability payments wasn’t reached until roughly two years after he returned from Iraq.

  Yet, essentially all that any medical professionals continued to do for Andrew was to encourage him to increase his medications. By September 2007, he was taking an astonishing 1,200 mg of Seroquel a day, along with other medications. “Is it safe?” Andrew asked during one clinic visit, and the clinicians there blithely reassured him he had nothing to worry about. “He appeared to tolerate it, and he seemed to be okay,” Schauland adds.

  Andrew’s parents knew he needed more specialized help than the local VA system was providing, but their efforts to get him treated at the residential PTSD unit in the VA’s Clarksburg, West Virginia, hospital were stymied by the agency’s Catch-22 rules. Even as the national VA was tacitly encouraging the use of antipsychotics and Klonopin with PTSD patients, the Clarksburg PTSD residential unit declined to admit patients who had been prescribed those very same drugs by local VA doctors. “They refused to take him because he was on medication,” Stan White says. Prodded by the VA’s Inspector General, the hospital ultimately altered its absurdly restrictive policy after Andrew White died.

  As Andrew continued to unravel in that fall of 2007, his parents started to look outside the VA system for psychiatric help for their son, where they found the area’s most highly recommended psychiatrist for treating PTSD, Dr. Lawrence B. Kelly. Kelly was also, in the eyes of Big Pharma marketers, an influential medical “key opinion leader” (KOL) worth paying to hype their drugs, according to recent corporate disclosures. It wasn’t until its settlement with the DOJ in 2010, though, that AstraZeneca began to stop paying doctors to tout Seroquel for the sort of off-label uses that contributed to Andrew’s death. Kelly declined to comment or answer phone calls on his receipt of drug payments, although records show he received roughly $30,000 from drug companies in 2010 through 2012.

  But in 2007, when Shirley accompanied Andrew to some initial visits, no major companies disclosed their payouts. So there was no way of knowing for sure why this expert doctor joined the VA in thinking that the best solution was to increase Andrew’s Seroquel dosage up to 1,600 mg under his direction, along with Paxil, Klonopin and other meds. While White did talk about his nightmares of all those dead Iraq bodies during those sessions, he got little else from his treatment except more side effects. These included severe constipation and a plummeting libido in addition to weight gain and glandular effects. Still, the switch to the new psychiatrist also seemed to offer a few glimmers of hope: he began planning a trip to the beach in the summer, a small but important sign that he was looking ahead to the future.

  When the PTSD group he had been regularly going to began falling apart in mid-November 2007, one of the few stabilizing forces in his life was yanked away. “He lost contact with that weekly regimen of meeting with his friends,” Shirley White says. “He didn’t have anywhere to vent.”

  There was never any reason given by VA officials as
to why the support group was closed down. But Linzmaier was encouraging veterans to apply for benefits at a time when the agency’s de facto policy was to downplay the seriousness of PTSD and to thwart veterans’ access to care—a point later confirmed in the scathing federal appeals court ruling in 2011 decrying the VA’s “unchecked incompetence” in failing to deliver timely mental health services to veterans in need.

  In January 2008, Andrew was involuntarily committed to the decrepit Mildred Mitchell-Bateman Hospital in Huntington, West Virginia. Andrew ended up there after he had gone on a bender that included cocaine, triggered by a notice from the Marine Corps that he had been discharged on medical grounds. When he returned home, he holed up in his room with his Xbox and video war games, all his stress and frustration building throughout the weekend. By Monday, he was breaking items, hurling his Xbox controller at the TV and throwing his CDs across the lawn from the porch. A frightened Shirley White called a few friends that night to calm him down and convince him to get emergency help. But his rage spiraled out of control while waiting for hours to be seen at the nearby Charleston hospital, and he began threatening to kill a doctor who told him to simmer down. White’s original interest in admitting himself voluntarily had so backfired that the hospital’s medical staff, clueless about how to deal with PTSD patients, filled out a mental health warrant to commit him involuntarily.

  A 2008 state investigation report cited the Bateman mental hospital for overcrowded conditions and inadequate psychiatric care, but it was still operating unimpeded at the time Andrew was committed. Even then, after the decision to commit him on January 16th was reached, the disarray, ineptness and shortages in the local mental health system—common across the country—became evident once again. With no hospital bed anywhere, it wasn’t until the early morning hours when the court officers shipped him to Bateman in Huntington, which didn’t have space either, but reluctantly admitted him as the referral option of last resort.

  It became clear enough that the degradation he felt at being committed to Bateman didn’t speed his recovery. Instead, they slapped on new diagnoses and altered his medications yet again. He was now deemed to have bipolar disorder with psychotic features and PTSD. The doctors at Bateman stopped the Paxil and, with an eye towards boosting his chances of getting admitted to the restrictive Clarksburg PTSD program, took the risky step of suddenly stopping the anti-anxiety benzodiazepine he was taking, Klonopin. Unfortunately, that was a highly dangerous move that not only can induce panic attacks, psychotic symptoms and seizures, but can also lead to mistaken psychosis diagnoses—as apparently happened to White while at Bateman—all resulting from failing to gradually, carefully wean patients off the drug over several weeks. The medical staff also lowered his dosage of Seroquel to a still-dangerous 800 mg.

  Unfortunately, while Andrew was in the hospital, the deadly risk posed by taking Seroquel in combination with other drugs wasn’t apparent to the Whites—even after Eric Layne, a member of Andrew’s support group, was found dead on the couch by his wife on January 26th. Shirley White first learned of Eric’s death when she was on her way home from visiting Andrew. At the time, Eric’s family believed his death was due to kidney failure, but nobody really knew for certain.

  Andrew’s parents, though, made a decision not to tell him about Eric’s death while he was still in the hospital. “I think we just thought he would handle it better when he was home,” Shirley recalls.

  But if Eric’s death was a tragedy for all who knew him, the news was especially frightening and mysterious to fellow members of his support group, in part because he died just a day after being discharged from the residential PTSD program at the Cincinnati VA hospital. “He was the first one of us to die, and it was a shock,” says support group member Chris Tharp, who had even made plans with Eric to go the driving range together when he got back. “We didn’t know anything about medication,” he says.

  Once Andrew learned what happened to Eric, Tharp recalls, “It took him off guard and messed him up psychologically.” Andrew even joined in the search for answers but didn’t connect Eric’s medication use with his own. “By the time we came up with conclusions,” Tharp says, “it happened to Andrew.”

  The day after his discharge from Bateman, Andrew, still lacking any effective treatment but somewhat more relaxed, returned again to the snares of the VA’s hit-or-miss strategy for dealing with his PTSD. On February 2nd, joined by his mother, Andrew traveled to the Huntington VA hospital to meet with both a senior psychologist, Robert Huwieler, and his lead psychiatrist, Schauland, to start what was supposed to be, at last, a definitive treatment plan. He first saw Huwieler, who had thoroughly evaluated him the previous August for his PTSD disability claim. Even with all the medications he’d been prescribed, Andrew, restless and nervous at this session, was still reporting flashbacks and regular nightmares from his time in Iraq. Huwieler concluded that his condition had been marked by a “progressive worsening over time.”

  One obstacle, Huwieler noted, was that he had “extremely limited coping skills” for managing his PTSD symptoms. One key reason for this inability, of course, was that until then, no professional at any VA facility ever bothered to teach him such elementary coping strategies as using slow, deep breathing during stressful situations.

  Still, Huwieler showed a willingness to bend the rules for Andrew. He agreed to see him personally each week rather than relying on the VA’s scheduling obstacle course. Huwieler’s plan for Andrew: “Participate in individual cognitive-behavioral psychotherapy to learn and apply coping skills …”

  “We had to beg—honestly beg—to get him that extra treatment,” Shirley says.

  But it would prove to be too late. In the final weeks of Andrew’s life, his medications were adjusted yet again without regard for the risks involved. “If you are going to see us, it’s us only,” Schauland told Andrew. He had not seen White since October 2007, when he had increased his Seroquel dosage to a breathtaking 1,200 mg. “A fair amount of de-compensation has transpired,” Schauland later wrote in his notes about this February session, without raising any questions about his own prescribing strategy or the VA’s therapeutic failures. Schauland reinstated his previous drug regimen with the doses slated to be escalated: Paxil, Klonopin and, for now, Seroquel at 800 mg.

  With the new treatment plan in hand, Andrew, the VA’s clinical staff and his mother were all optimistic. “I really thought he was going to get better,” Shirley White says. “We were very upbeat on his last visit to Drs. Schauland and Huwieler.”

  The next week, Huwieler met with Andrew privately while his mother waited in the car. He came down the steps afterward with some new hope and the first tangible coping technique he was ever provided: a rubber band around his wrist. “He had on the rubber band, and it was suggested that any time he started thinking about Iraq, that he was to use that rubber band and snap it, and then that would bring him back to now,” Shirley recalls. “That was one of the strategies.” It was meant as one of the “grounding” methods used in cognitive therapy for a PTSD sufferer plagued by intrusive memories.

  When they returned home that Monday afternoon, he was smiling a bit more than usual as Shirley left to go to the Sylvan Learning Center franchise she and Stan owned. Stan was working at a Canaan Valley, West Virginia, resort for the ski patrol. With a snowstorm underway, Shirley returned home that night much later than usual. Knowing how anxious Andrew got when she wasn’t home on time, she called to reassure him three times on her way home.

  Yet when she got back, “he seemed to be doing well,” she says. He was speaking to his younger sister on the phone for about a half hour, talking about his plans for a dinner date with one of her friends the next evening. While Shirley stayed up late painting cabinets for a renovation, he chatted easily with her, asking for a twenty-dollar loan for tomorrow night’s date and making plans to meet Shirley at the cell phone store near her job at 1 p.m. the next day.

  It was getting late. About 10 p.m., s
he doled out, as usual, his prescribed medications, including Seroquel, but they continued talking until 11:30 p.m., when Andrew said he felt tired and started getting ready for bed. Nothing seemed particularly wrong, although his mother told him he looked very pale. Andrew just laughed it off. Since he often took their pet cat to his bedroom to help relax during his restless nights, she asked, “Do you need the cat to come up and spend the night?”

  “No, actually I feel pretty mellow this evening,” he said, heading up the stairs in his pajamas and T-shirt. That turned out to be the last time she ever spoke to him.

  The next morning, on her way out to work, she stopped by his room to put the twenty-dollar bill on his dresser drawer and turn out the bedroom light. Nothing disturbed the heavy snoring that typically marked his medicated sleep. At work at the Sylvan Center, she started calling before noon to the house phone and then his cell phone to make sure he would be awake in time for their appointment. With no answer, she soon started calling the numbers again and again, and was growing increasingly frantic. She then called on a neighbor to check on him. The neighbor went over to the house twice, pounding on the front door and his bedroom window without getting any response.

  “I think something’s wrong,” she told Shirley by phone at about 3 p.m.

  Shirley rushed home in her car, hoping that her worst fears weren’t coming true. When she ran into the house and up the stairs to his room, she found her youngest son Andrew lying on his side in his bed, deathly still and facing the wall. It was mounted with pictures of his Marine buddies, his Xbox controller and the white dress Marine cap he once wore with pride. She cried in anguish at what she saw: it was obvious that he had stopped breathing and was almost certainly dead. She called 911 anyway, but the paramedics couldn’t revive him. Even today, this shy woman—who has gone public in a crusade to change the VA’s mental health treatment of veterans—breaks down in tears at the memory of those final horrifying moments that ended her son’s long struggle to get effective help. All she will say about it now is: “It’s painful.”